Correct Diagnosis of Hypertension
To the Editor: The article titled "Practical Approach to theManagement of Hypertension in the Elderly" (October 2007)is a good review of the importance, diagnosis, and treatment ofhypertension. However, several points in the article requiresome comments. First, isolated systolic hypertension is definedas a systolic blood pressure (BP) greater than 140 mm Hg anda diastolic BP of less than 90 mm Hg; the article erroneouslysays ">90 mm Hg." Second, hypertension is sustained elevationin BP reading greater than 140/90 mm Hg. An outpatient settingrequires at least 2 separate office or clinic readings of BPgreater than 140/90 mm Hg, with an in-between BP readingsinterval that ranges from 1 to 2 months, or less, depending onthe initial BP reading. In a hospital/inpatient setting, one needsto consider anxiety, acute illness, acute stress, and insomnia asa cause of elevated BP, which requires previous or repeat BPreadings to confirm and diagnose hypertension. So-called whitecoat or isolated clinical hypertension should also be considered,requiring the use of home or ambulatory BP monitoring. Thepatient should have an appropriate-size cuff and be asked to refrainfrom smoking or caffeine ingestion for 30 minutes beforeBP measurement.
Finally, screening for secondary hypertension is not warrantedin most cases, because this occurs in only 5% to 10% of allpatients with hypertension. Consider screening when hypertensionoccurs in one of the following categories: in those youngerthan 30 years or those older than 50 years; in those with significantend-organ target damage at diagnosis (eg, left ventricularhypertrophy, renal insufficiency, hemorrhages, or exudates oneye examination); those with poor response to 3 appropriateantihypertensive drugs (with 1 being a diuretic), in addition tothe factors mentioned in the article.
Kayode C. Lawrence, MD
Maryland General Hospital, Baltimore
The Authors Reply: We thank Dr Lawrence for his valuablecomments on our paper. We agree that isolated systolic hypertensionis defined as a systolic BP more than or equal to 140 mm Hgand a diastolic BP of less than 90 mm Hg. We regret the typographicalerror, which resulted in a diastolic BP being reported asmore than 90 mm Hg. We further agree with Dr Lawrence thatclinicians should account for factors affecting the diagnosis of hypertension,as listed in his letter. The diagnosis of hypertension requiresat least 2 separate office readings of BP more than or equalto 140/90 mm Hg, taken at least 1 week apart. Finally, we concurthat physicians should only consider secondary causes of hypertensionwhen the conditions above and in our article are present;nonessential hypertension is usually a rare entity.
Shakaib U. Rehman, MDJan N. Basile, MD